Zu einem gehäuften Auftreten von Explosionsverletzungen kommt es in der Silvesternacht durch Feuerwerk. Bei dem Versuch Feuerwerk herzustellen, kommt es zur Explosion der in einem Mörser gemischten Substanzen. Die linke Hand des Patienten wird schwer verletzt. Im Rahmen der operativen Versorgung mit radikalem Débridement und großzügiger Amputation ohne osteosynthetische Versorgung konnte zunächst die „basic hand“ nach Entin erhalten werden. Im Verlauf war ein Erhalt des 4. Fingers nicht möglich, sodass eine Prothesenversorgung notwendig wurde. Dieser Fallbericht zeigt die Wichtigkeit von handchirurgischer Expertise in der Versorgung von solchen schweren Verletzungen. Eine „Toe-to-hand“-Transplantation stellt eine weitere Therapiemöglichkeit dar.

Five years before hospitalization a 72-year-old woman was first found to have anaemia. Shortly thereafter she had noticed blood on her stool, but endoscopy had failed to find the origin of the bleeding. Selective mesenteric angiographies, diagnostic laparoscopy and contrast radiography of the small intestine (after Sellink) as well as scintigraphy during the subsequent years had all been negative, although there had been several severe bleedings. Admission was prompted by renewed severe peranal blood loss. The patient was found to be obese but in a poor general state. Her skin was pale, blood pressure was 80/60 mmHg, heart rate 130/min. The abdomen was soft and without resistance on palpation.Haemoglobin was 5.7 g/dl, haematocrit 26%. Quick value, partial thromboplastin time and prothrombin time were normal. Emergency esophagogastroduodenoscopy and coloscopy as well as angiography again failed to find the source of bleeding.The circulation was stabilized with infusion of 4 units of erythrocyte concentrate and 2000 ml 10% hydroxyethylstarch. The blood pressure again dropped 2 days later. In parallel to renewed volume substitution another angiography was performed. This revealed arteriovenous shunts with ectasias in the terminal ileum. A right hemicolectomy was performed. The resected specimen showed intestinal angiodysplasia. At follow-up 6 months later the patient was symptom-free and there had been no further bleeding.Even selective angiography of the superior mesenteric artery sometimes fails to demonstrate intestinal angiodysplasia. The diagnosis may then be made by repeat angiography during the phase of acute bleeding.

BACKGROUND:Traumatic hip dislocation combined with fracture of the femoral head is a rare condition for which little known in terms of long-term prognosis. The aim of the retrospective study presented here was to evaluate the clinical and radiological outcome of this specific injury.PATIENTS AND METHODS:In a 23 year period, 18 patients (17 male) with an average age of 25.6 (range 15-55 years) were treated. There were four type-I, three type-II, no type-III, and 11 type-IV fractures according to the Pipkin classification (1957).RESULTS:The average time to sufficient reduction was 136 min (60-420 min), two by open means. A total of 16 patients were operated for open reduction and internal fragment fixation, 13 through a dorsal approach. All patients filled out a standardized questionnaire, and clinical and radiological examinations were also carried out on average 12.6 years (range 59-247 months) after injury. Four scoring systems were used to classify the outcome: Thompson and Epstein (1951): very good = 1, good = 10, fair = 4, poor = 3; Merle D'Aubigne (1954): very good = 9, good = 5, fair = 0, poor = 4; Harris (1969): Pipkin I = 81 points, Pipkin II = 97 points, Pipkin IV = 73 points (mean); Brooker (1973): grade I = 5, grade II = 1, grade IV = 2.CONCLUSION:Quality of life was not reduced in most patients in the long term, however three of four patients suffering Pipkin type-IV fractures developed functional restrictions with poor results. We conclude that acute reduction of the dislocated joint and anatomical reconstruction of the femoral head instead of primary hip replacement may end in good to excellent results in type-I and type-II fractures. Due to the young age of these patients, joint reconstruction should always be the first choice even in type-IV fractures with a higher probability of poor prognosis.

Die Hüftkopffraktur ist als „proximalste“ Form der Femurfraktur eine sehr seltene Verletzung, über deren Prognose relativ wenig bekannt ist. Ziel der vorgestellten retrospektiven Studie war die Evaluation der Spätergebnisse von Hüftkopffrakturen.

Various intramedullary nail systems have been established for the treatment of per- and subtrochanteric femoral fractures. This study focused mainly on the advantages and disadvantages of implementing a new intramedullary nail system named the PLATON nail. One hundred and thirty patients who had per- and subtrochanteric femoral fractures were treated using the intramedullary PLATON nail over the period from September 2001 until May 2003. The median age of these patients was 76 (range: 39-98) years with a predominance of female patients (3 : 1). The classification of the fractures was determined with regard to Evans and the AO guidelines. Patient compliance was recorded, as well as clinical and radiographic examinations for each patient. The 130 operations were conducted by 28 surgeons. The mean time of surgery was 54 minutes. A closed reduction of the fracture preceded the locking nail implantation in 94 % of the cases. The insertion of the nail was found to be easy by 93 % of the surgeons. A lateral movement of the femoral lag screw due to displacement was seen in 5 cases. Infection and haematoma were observed in 5 patients. Compared to other similar implants, the cut-out rates, secondary fractures, implant failures and the need for revision were lower. On the other hand, the incidences of infection, haematoma and irritation are comparable to other implants. While the differences between the PLATON nail and other types of systems were moderate in many respects, a visible reduction of cut-out and secondary fractures were indicated by this study.

In the field of local application of antimicrobials, a number of novel drugs and/or new drug delivery systems have been developed in recent years. The present study aimed to investigate hydroxyapatite cement (HAC) as a carrier for vancomycin in the treatment of chronic osteomyelitis due to Staphylococcus aureus strains with various mechanisms of resistance. The release of vancomycin from standard test cylinders was determined in vitro and the efficacy of the delivery system was measured in vivo using a rabbit model of chronic osteomyelitis. First, powdered HAC was mixed with vancomycin at 80, 160 and 240 mg/g. After hardening, formed cylinders were eluted in phosphate buffer and antibiotic release was measured by agar diffusion. High levels of release (1512+/-318 to 1937+/-336 microg/ml) were obtained for 12 to 20 days depending on the dosage of vancomycin. Additionally, bone infection was induced in the tibia of 30 New Zealand white rabbits by injecting either a methicillin-resistant S. aureus strain (MRSA) or a S. aureus strain with a small colony variant (SCV) phenotype. After 3 weeks (chronic infection), all animals were treated by debridement. Moreover, group 1 (challenged with SCVs) and group 2 (challenged with MRSA) were treated by filling the marrow with HAC alone, whereas in groups 3 (SCVs) and 4 (MRSA) the marrow was filled with HAC/vancomycin (160 mg/g). After 6 weeks all animals were sacrificed. At 3 weeks, pathogens were detected in 24 of 30 animals. All swabs of the control groups, positive for S. aureus on day 21, were also positive on day 42 and S. aureus strains recovered were shown to be clonal to the strains used for induction of osteomyelitis. By contrast, no growth was found in the treatment group following 7 days of incubation in BHI bouillon. HAC/vancomycin-treated animals showed no histological evidence of infection on day 42. In the other groups, different stages of chronic osteomyelitis were found histologically. No local or systemic side effects due to HAC or vancomycin were seen. HAC is an effective carrier material for antibiotic compounds even in refractory infections due to MRSA or S. aureus SCVs.

ABSTRACT The therapeutic efficacy of an antimicrobial peptide, human lactoferrin 1-11 (hLF1-11), was investigated in a model of chronic methicillin-resistant Staphylococcus aureus (MRSA) (gentamicin susceptible) osteomyelitis in rabbits. We incorporated 50 mg hLF1-11/g or 50 mg gentamicin/g cement powder into a calcium phosphate bone cement (Ca-P) and injected it into the debrided tibial cavity, creating a local drug delivery system. The efficacy of hLF1-11 and gentamicin was compared to that of a sham-treated control (plain bone cement) ( n = 6) and no treatment (infected only) ( n = 5). The results were evaluated by microbiology, radiology, and histology. MRSA was recovered from all tibias in both control groups ( n = 11). On the other hand, hLF1-11 and gentamicin significantly reduced the bacterial load. Furthermore, no growth of bacteria was detected in five out of eight and six out of eight specimens of the hLF1-11- and gentamicin-treated groups, respectively. These results were confirmed by a significant reduction of the histological disease severity score by hLF1-11 and gentamicin compared to both control groups. The hLF1-11-treated group also had a significantly lower radiological score compared to the gentamicin-treated group. This study demonstrates the efficacy of hLF1-11 incorporated into Ca-P bone cement as a possible therapeutic strategy for the treatment of osteomyelitis, showing efficacy comparable to that of gentamicin. Therefore, the results of this study warrant further preclinical investigations into the possibilities of using hLF1-11 for the treatment of osteomyelitis.

A study was performed to investigate the effectiveness of hydroxyapatite cement (HAC) as a new carrier system in the treatment of chronic. posttraumatic osteomyelitis.In the in vitro study, release of gentamicin from standard cylinders of HAC were measured by agar diffusion test. As a representative for mechanical properties, compression strength was measured in order to detect changes when mixing HAC with gentamicin.In the in vivo study, bone infection was induced according to the model of Norden by injection of 1 ml Na-morrhuat and 3 x 10(6) CFU Staphylococcus aureus. After 3 weeks, when chronic stage of infection was obtained, 17 animals were treated by debridement and filling the marrow either with HAC alone or HAC mixed with gentamicin (32 mg/g). Animals of the control groups were left untreated. After 6 weeks, all animals were sacrificed. Hematological, radiological, microbiological and histological examinations were carried out by covered investigation.Best evidence of the efficiency of treatment was observed in histopathological and microbiological findings. In all swabs of the control groups, taken 6 weeks following infection S. aureus were detected which were clonal to the strain used for induction of osteomyelitis. In HAC/gentamicin-treated animals, no growth was detectable after 7 days of culturing in BHI bouillon. In the HAC/ gentamicin-treated group, there was no histopathological evidence of infection. In all other groups different stages of chronic osteomyelitis were found. No side effect was observed, neither locally nor systemically by HAC or gentamicin. Therefore, HAC is considered to be a very effective carrier for antibiotics in treatment of chronic, posttraumatic osteomyelitis. (C) 2003 Elsevier Ltd. All rights reserved.

AIM:Intramedullary nailing is the treatment of choice for the stabilization of fractures of long tubular bones. An important disadvantage of this method is the increase in intramedullary pressure and the resulting release of fat into the venous blood system during reaming of the medullary canal. We have developed a new type of rinsing-suction-reamer (SSB) in order to minimize these disadvantages. Trials were initiated to investigate whether it is possible to ream the medullary canal with the SSB without pressure increase in comparison with the standard AO-reamer (AOB).METHODS:Reamed intramedullary nailing was performed in 20 isolated pig femora. The intramedullary pressure was recorded continuously.RESULTS:While stepwise reaming was performed, the pressure only rose above the physiological level in AOB. During insertion of the guide wire and the nail, comparable values were measured for AOB and SSB.CONCLUSION:Our experiments show that reaming of the medullary canal is possible without a pressure increase using the SSB in comparison with AOB.

Use of intramedullary reamers (IR) is typically associated with pressure generation during the reaming process, which may result in the introduction of fat and marrow particles into the venous system. Thus, a new System was designed in order to avoid pressure generation and thus to reduce the risk of embolic events. In vitro testing was carried out using pig femura. Intramedullary pressure was recorded during drilling with either the new pressure-free intramedullary reamer (PF-IR; n = 10) or a Standard AO-IR (n = 10). For in vivo testing, nailing of the femur was performed in sheep using either the PF-IR (n = 7) or the Standard AO-IR (n = 7). Fat intravasation was measured using echocardiography and the Gurd test. Hemodynamic and pulmonary parameters as well as intramedullary pressure were continuously recorded during the experiments. The animals were then sacrificed and tissue samples were taken from all regions of the lungs. The incidence of lung fat emboli in histological sections was scored in a blinded manner. A finite element analysis was carried out to assess Performance of the PF-IR under load. The in vitro tests showed that the new PF-IR resulted in significantly less intramedullary pressure (15 ± 12 mm Hg) than the Standard AO-IR (813 ±247 mm Hg; p< 0.001, Mann-Whitney-U test). These results were confirmed in vivo. Moreover, the PF-IR group had significantly less fat intravasation (Gurd test) and better hemodynamic and pulmonary values than the AO-IR group. The incidence of fat microemboli in the lungs was reduced by 90% in the PF-IR group. Finite element analysis showed that the new drilling System performed well under load. The newly developed pressure-free IR clearly outperformed a Standard AO-IR. Use of the new PF-IR was associated with low intramedullary pressures, significantly less fat intravasation, and a markedly lower incidence of fat emboli in the lung. This, in turn, may have been the reason for the better hemodynamic and pulmonary values in the PF-IR group.

Use of intramedullary reamers (IR) is typically associated with pressure generation during the reaming process, which may result in the introduction of fat and marrow particles into the venous system. Thus, a new system was designed in order to avoid pressure generation and thus reduce the risk of embolic events. In-vitro testing was carried out using pig femura. Intramedullary pressure was recorded during drilling with either the new pressure-free intramedullary reamer (PF-IR; n = 10) or a standard AO-IR (n = 10). For in vivo testing, nailing of the femur was performed in sheep using either the PF-IR (n = 7) or the standard AO-IR (n = 7). Fat intravasation was measured using echocardiography and the Gurd test. Hemodynamic and pulmonary parameters as well as intramedullary pressure were continuously recorded during the experiments. The animals were then sacrificed and tissue samples were taken from all regions of the lungs. The incidence of lung fat emboli in histological sections was scored in a blinded manner. A finite element analysis was carried out to assess performance of the PF-IR under load. The in-vitro tests showed that the new PF-IR resulted in significantly less intramedullary pressure (15 ± 12 mm Hg) than the standard AO-IR (813 ± 247 mm Hg; p < 0.001, Mann-Whitney U-test). These results were confirmed in-vivo. Moreover, the PF-IR group had significantly less fat intravasation (Gurd test) and better hemodynamic and pulmonary values than the AO-IR group. The incidence of fat microemboli in the lungs was reduced by 90 % in the PF-IR group. Final element analysis showed that the new drilling system performed well under load. The newly developed pressure-free IR clearly outperformed a standard AO-IR. Use of the new PF-IR was associated with low intramedullary pressures, significantly less fat intravasation, and a markedly lower incidence of fat emboli in the lung. This, in turn, may have been the reason for the better hemodynamic and pulmonary values in the PF-IR group.

In einem 5-Jahres-Zeitraum (1993-1997) wurden 76Patienten mit einer Achillessehnenruptur operativ in der Technik nach Bunnel versorgt. Ab dem 5. postoperativen Tag wurde mit einer dynamischen Nachbehandlung in einer speziell konzipierten Schiene unter Vollbelastung begonnen. Die gesamte Behandlungsdauer dauerte 6 Wochen. Nach 1 und 2 Jahren erfolgte die Nachuntersuchung von 73 Patienten („drop out“ 3,9%, n=3).

ZusammenfassungHandgelenksfrakturen betreffen am häufigsten den distalen Radius. Seltener sind Frakturen des Os scaphoideum sowie Frakturen und Luxationen der übrigen Handwurzelknochen, die an dieser Stelle keine Berücksichtigung finden sollen.

Insgesamt wurden 284 Patienten in die prospektive Studie aufgenommen und nach einem Jahr klinisch nachuntersucht. Die Versorgung der Frakturen richtete sich ausschließlich nach dem Frakturtyp und unabhängig vom Alter. Die bis zu 65 Jahre alten Patienten und die über 65jährigen wurden vergleichend hinsichtlich des funktionellen Langzeitergebnisses ausgewertet. Die Spätergebnisse nach mindestens einem Jahr unterschieden sich weder nach funktionellen, noch nach radiologischen Kriterien signifikant zwischen beiden Gruppen. In beiden Gruppen ergaben sich über 70% sehr gute und gute Resultate nach der Klassifikation von Gartland und Werley (73,9% bei den über 65jährigen und 71,8% bei den jüngeren Patienten). Die radiologische Sinterung des Radius war ebenfalls statistisch nicht signifikant. Bei älteren Patienten sind demnach bei vergleichbaren Frakturen ebenso gute funktionelle Ergebnisse erzielbar.

The aim of the present study was to investigate hydroxyapatite cement (HAC) as an in vivo setting composite of tricalcium phosphates to be used as a carrier for the local application of antibiotics in a three-step research program: Elution of gentamicin and vancomycin from HAC in vitro, changes in the mechanical properties of HAC mixed with these antibiotics and in vivo investigation of the efficacy of the delivery system in an experimental model of chronic osteomyelitis. Our data suggest that HAC is a highly biocompatible in vivo setting bone cement for bone void filling. By replacing water with antibiotic solution HAC can be a convincing carrier. Neither the active substance nor the mechanical properties were disturbed by mixing in the used range of concentrations. Because of its prolonged release of high levels of antimicrobial agents this delivery system obtains long-term antibacterial effectiveness locally. Side effects of the antibiotic were not observed. Our in vivo study shows a positive effect on the course of experimental osteomyelitis.

A .375 Holland & Holland Magnum Winchester Fail Safe bullet was fired against a steel plate. The big-game hunting bullet (17.4 g, approx. 810 m/s) has a solid copper-alloy hollow point design including a lead core limited to the rear portion. The range of firing was 20 m and the angle of impact was 90°. A large fragment (10.9 g) consisting of the main part of the copper portion was deformed in a peculiar manner similar to a tube or ring and wounded the left hand of the person shooting. The unique fragment trajectory strictly against the line of fire and the velocity sufficient to shatter bone after a distance of 20 m can be explained by an extraordinary deformation mechanism. Unlike in tissue, the high resistance of the steel plate caused the lead core in the rear of the bullet to move forward perforating the central copper barrier behind the hollow point cavity. Thus, the peculiar fragment was created. The subsequent backwards acceleration of the ring-like fragment was probably caused by the partly elastic impact of the copper-alloy portion against the hard steel plate. Due to the perpendicular impact resulting in a centric and symmetrical deformation, the fragment moved in a direction exactly backwards along the original line of fire.

The Essex-Lopresti lesion, a combination of radial head fracture and distal radioulnar dislocation, rarely occurs but nevertheless represents a frequently unknown result after forearm fracture. The responsible physician soon has to initiate surgical treatment to prevent his patient from permanent pain of the wrist. Previously unrecognised distal radioulnar dislocation remains to be an unsolved problem. A generally accepted management concept does not exist. Since rupture of the membrana interossea nearly ever occurs, resection of the radial head is followed by radial shifting and seems to be obsolete under these circumstances. An exemplary case is presented and surgical management in this situation is discussed.

Following curettage of enchondromata of the phalanges we filled the resultant bone cavity with hydroxyapatite cement in eight patients to avoid cancellous bone grafting. This material differs significantly from the ceramic hydroxyapatite commonly used in clinical practice. It is produced by the combination of two calcium phosphates which, in the presence of water, form a paste that cures to a solid implant with a microporous structure. Like ceramic hydroxyapatite, this cement is highly biocompatible and does not provoke a foreign body giant cell reaction, a sustained inflammatory response or a toxic reaction. We performed a prospective study with X-rays and clinical assessment up to 1 year after the operation. There were no complications, and all patients regained full function of the hand.